Crit Care Resusc
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Misdiagnosis of the cause of illness in critically ill patients is common, and a major cause of morbidity and mortality. We reflect upon a misdiagnosis that occurred in the intensive care unit of a metropolitan teaching hospital, and highlight the susceptibility of medical decision making to error. ⋯ We discuss the vulnerability of such processes and - with particular reference to our case - why even knowledgeable and diligent clinicians are prone to misdiagnose. Finally, we review potential solutions, both educational and systemic, that may guard against the inevitable failings of the human mind, especially in a busy modern intensive care setting.